penn center for evidence-based practice hospital-based comparative effectiveness centers: improving...
TRANSCRIPT
PENN CENTER FOR EVIDENCE-BASED PRACTICE
Hospital-based Comparative Effectiveness Centers: Improving the Quality, Safety and Cost-Effectiveness of Patient Care Thru Evidence-based Practice at the Systems Level
Craig A Umscheid, MD, MSCE, FACP
Assistant Professor of Medicine and Epidemiology
Director, Center for Evidence-based Practice
Medical Director, Clinical Decision Support
Senior Associate Director, ECRI-Penn AHRQ EPC
TEACH Plenary
August 8th, 2013
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Outline
Case Defining CER and HTA Practicing EBM at a “systems” level thru hospital-based HTA
• Synthesizing evidence for decision-making• Clinical decision support• Education in EBM
Conclusions
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Case: Chlorhexidine to Reduce Surgical Site Infections
Betadine: 60 cents per patient
Chlorhexidine: $13 per patient
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Usual Decision Making Practices in U.S. Hospitals
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Usual Practice in U.S. Hospitals (cont)
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Is there a better way?
How about CER and HTA?
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Comparative Effectiveness Research
Comparison of two approaches of care
Comparison based on “effectiveness” (i.e. how well an approach works in real world settings)
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Health Technology Assessment
Also referred to as Healthcare Technology Assessment or Medical Technology Assessment
Form of policy research that systematically examines short and long term consequences of a health technology
Technologies are defined broadly as drugs, devices, procedures, and processes of care
Outcomes can include efficacy, effectiveness, safety, cost, ethical or social consequences
Goal is to inform decision making in policy and practice (as opposed to the goal of research, which is often to contribute to generalizable knowledge)
IJTAHC. 25: Supplement 1 (2009)
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CER, HTA and EBM: Clearing the Confusion
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What is Hospital-based HTA / CE ?
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Hospital-based Health Tech Assessment
J Gen Intern Med. 2010; 25(12):1352–5.
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National vs. Local HTA / CE Centers
Umscheid et al. JGIM. 2010; 25(12): 1352-55.
Goals are different: Information for general decision making vs. local decision making.
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Quality and safety of health care
Quality and safety of health care
Stagnant reimbursements
and increasing costs
Stagnant reimbursements
and increasing costsPublic reporting and pay-for-performancePublic reporting and pay-for-performance
Cost-effectiveness of health care spending
Drivers of Evidence-based Practice
Evidence Based Practice at the Systems Level
Evidence Based Practice at the Systems Level
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Quality and safety of health care
Quality and safety of health care
Stagnant reimbursements
and increasing costs
Stagnant reimbursements
and increasing costsPublic reporting and pay-for-performancePublic reporting and pay-for-performance
Cost-effectiveness of health care spending
Drivers of Evidence-based Practice
Evidence Based Practice at the Systems Level
Evidence Based Practice at the Systems Level
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International Models for HB-HTASlides courtesy of Marco Marchetti, Director, HTA Unit, A. Gemelli University Hospital, Rome, Italy
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Models of HB-HTA in the US
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Kaiser Permanente (KP)
KP Southern California Region Technology Inquiry Line KP National Drug Information Service Interregional New Technologies Committee
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KP Southern CA Technology Management Process
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Penn Medicine Center for Evidence-based Practice (CEP)
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Office of CMO Organizational ChartPenn Medicine CEOPenn Medicine CEO
Penn Medicine CMOPenn Medicine CMO
Center for Evidence-based PracticeCenter for Evidence-based Practice
Clinical Effectiveness & Quality ImprovementClinical Effectiveness & Quality Improvement
Graduate Medical EducationGraduate Medical Education
Office of Medical AffairsOffice of Medical Affairs
Office of Patient AffairsOffice of Patient Affairs
Patient Safety OfficersPatient Safety Officers
Regulatory AffairsRegulatory Affairs
Infection ControlInfection Control
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Center for Evidence-based Practice: Mission and Approach
• Perform reviews of the medical literature to inform clinical practice, policy, purchasing and formulary decisions in and outside of Penn
• Help translate evidence into practice at Penn through computerized clinical decision support (CDS)
• Offer education in evidence-based decision making to trainees, staff and faculty in and outside of Penn
“To support the quality, safety and value of patient care at Penn through evidence-
based practice.”
“To support the quality, safety and value of patient care at Penn through evidence-
based practice.”
Umscheid et al. JGIM. 2010; 25(12): 1352-55.
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Framework for Evidence-based Guidance
1. Define the clinical issue of concern
2. Perform systematic search for existing evidence
3. Identify or develop best practices
4. Implement best practices
5. Monitor the impact
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Clients Served
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Technologies Reviewed and Report Types
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Select Evidence Report Topics
Processes of care •Routine replacement of peripheral IVs versus replacement only “as needed”
•Post-discharge telephone calls to reduce readmissions
Devices•Indications for robot assisted surgery
•Antimicrobial sutures and prevention of surgical site infections
Drugs
•Celecoxib versus other NSAIDs for post-operative pain control
•Colchicine to prevent atrial fibrillation and pericarditis after heart surgery
Diagnostic Tests
•Screening tests for risk of hospital readmission
•Screening tests for risk of aspiration
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CEP Reports by Fiscal Year
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Dissemination and Implementation (FY07-13)
Modes of Dissemination N
Internal Penn Website 207
HTA Database or National Guideline Clearinghouse
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Peer-reviewed Publications (26 based on CEP reports)
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Clinical Decision Support 35
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External Collaborations: CDC and AHRQ
Centers for Disease Control and Prevention (CDC)• Infection control guidelines
Agency for Healthcare Research and Quality (AHRQ)• One of 11 centers nationally awarded an “AHRQ Evidence-based
Practice Center” contract• Perform evidence reviews to inform clinical practice guidelines and
other forms of national healthcare policy
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Computerized Clinical Decision Support (CDS)
“Provides clinicians or patients with knowledge and information, intelligently filtered or presented, to enhance patient care.”
• Alerts (e.g., drug allergies or interactions)• Reminders (e.g., about best practices)• Order sets
www.himss.org/cdsguide
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2012 Annals CDS Review
148 RCTs 128 (86%) assessed health care process measures 29 (20%) assessed clinical outcomes 22 (15%) assessed costs Majority of studies were “good” quality Majority of studies were in academic institutions, ambulatory
settings, using locally developed CDS Both commercially and locally developed CDSs improved health
care process measures Evidence for clinical and economic outcomes was sparse Few studies measured potential unintended consequences or
adverse effects
Bright TJ et al. Effect of Clinical Decision-Support Systems: A Systematic Review. Ann Intern Med. 2012;157(1):29-43.
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Predictors of Improved Practice with CDS
Meta-regression identified success features, including: • integration with charting or order entry system• local user involvement in development• automatic provision of decision support as part of clinician workflow• provision of decision support at time and location of decision-making• provision of a recommendation, not just an assessment
Lobach D et al. Evidence Report No. 203. (Prepared by the Duke Evidence-based Practice Centerunder Contract No. 290-2007-10066-I.) AHRQ Publication No. 12-E001-EF. Rockville, MD:Agency for Healthcare Research and Quality. April 2012.
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CDS Five Rights ModelTo improve care outcomes with CDS one must provide:
the Right Information…
Evidence-based, useful for guiding action
…to the Right Stakeholder…
Both clinicians and patients
…in the Right Format…
Alerts, Order Sets, etc.
…through the Right Channel…
Internet, mobile devices, electronic health records
…at the Right Point in the Workflow.
To influence key decisions/actions
www.himss.org/cdsguide
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CDS Mission at Penn
To continuously improve the safety, quality, and efficiency of patient care by ensuring that
providers have the information needed to drive decisions that lead to optimal outcomes.
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Primary CDS Activities at Penn
1. Evaluating and prioritizing new CDS proposals
2. Developing and deploying CDS interventions
3. Cataloguing and evaluating implemented interventions
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Structure of Clinical IT Governance
Clinical ITGovernance Committee
Inpatient EMRCommittees
Outpatient EMRCommittees
Inpt CDS Workgroup
Outpt CDS Workgroup
Clinical Decision SupportCouncil
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IT Report Writer
CDS Program Officer (PO)
CDS Workgroup
IT Analyst
Requestor of CDS
Intervention
CDS Workflow
Key Stakeholders
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CEP CDS Interventions
35 CEP reports have informed decision support interventions embedded in Penn’s electronic health record, including: • Venous thromboembolism prophylaxis• Readmission risk flag• Foley catheter removal alert• Albumin order set• Red blood cell transfusion order set• Nurse-driven protocol for vaccine assessment and administration• Early warning system for sepsis• Delirium management order set
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223 pages!
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CDS to Increase Use of Clot Prevention Meds
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Clot Prevention CDS (continued)
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Proportion of Inpatients with Clot Prevention Meds
Umscheid CA, et al. BMC Medical Informatics. 2012 , 12:92
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Risk Factors for 30 Day Readmission
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Predictors of Readmissions from Review
Healthcare resource utilization • Length of stay, number of prior admissions, and previous ED visits• Studies have not consistently identified threshold values for these
predictors
Patient characteristics• Comorbidities, living alone, discharged to home, and payor• Evidence is mixed regarding other factors, including age and gender
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Implementation: Readmission Risk Flag
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Test Characteristics
Sensitivity Specificity PPV NPVScreen Positive
40% 85% 33% 89% 18%
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CDC Guideline on Preventing Urinary Catheter Infections
Full guideline at http://www.cdc.gov/hicpac/index.html
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CDS to Reduce Urinary Catheter Use
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Number of “Remove Catheter” Orders Placed Within 10 Minutes of Alert
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Albumin CDS Screenshot
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CEP Educational Efforts
Faculty and Staff Education
• “Academic detailing” thru distribution of InfoPOEMs and PROVE
• Critical Appraisal certificate course
• Local and national conferences and workshops
Fellow Education
• Systematic Review and Meta-analysis course
Resident Education
• High Value Care Curriculum
• Healthcare Systems Leadership and Quality Improvement Track
• Clinical Investigator Toolbox
Medical Student Education
• Direct medical student EBM curriculum
• Small group instructors in Epidemiology and Health Policy courses
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Back to Our Case: Chlorhexidine
Betadine: 60 cents per patient
Chlorhexidine: $13 per patient
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Chlorhexidine Evidence Review
Lee I, Agarwal RK, Lee BY, Fishman NO, Umscheid CA. Infection Control and Hospital Epidemiology. 2010; 31(12): 1219-29.
HUP Surgical Site Infection Data – FY07
Type of Cases Number Cost per case
Infected 285 $13,537
Uninfected 21,584 $5,356
Inf ec tion0 .0 0 9
$13550; P = 0.0 09
No inf ec tion0 .9 9 1
$5369; P = 0.99 1
Chlorhex idine$5443
Inf ec tion0 .0 1 3
$13537
No inf ec tion0 .9 8 7
$5356
Betadine$5462
W hich antiseptic should UPHS u seChlorhex idine : $5 443
Decision Analysis - Assume 25% reduction
Analysis suggested annual hospital savings of $415,511 with Chlorhexidine
Lee I et al. Infection Control and Hospital Epidemiology. 2010; 31(12): 1219-29.
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Conclusions
Evidence-based decision making impacts quality, safety and cost-effectiveness of care delivered to patients.
Despite this, infrastructures or centers to support such decision making in U.S. hospital and health care systems are not common.
Penn Medicine’s Center for Evidence Based Practice (CEP) is one of only a few academically based centers in the US with internal and external funding to support such work.
Penn’s CEP is enthusiastic about collaborating in the domains of operations, research and education to improve the quality, safety and value of care thru a systems approach to evidence-based practice.
